Treatment Strategy for Pyoderma Gangrenosum: Skin Grafting with Immunosuppressive Drugs
, Kento Mizutani 1, Naho Yokota 1, Hiroyuki Goto 1, Tomoko Akeda 1, Hiroshi Kitagawa 1, Koji Habe 1, Akinobu Hayashi 2 and Keiichi Yamanaka 1,*Round 1
Reviewer 1 Report
Interesting discription of several cases / case series but can be improved.
This histological figures are very low resolution and can not be assessed. Please describe clearly what ethical approval process was reached to make this a novel treatment. If it is not novel why present it as a case series?!
Author Response
Responses to the comments of Reviewer #1
Interesting discription of several cases / case series but can be improved.
This histological figures are very low resolution and can not be assessed. Please describe clearly what ethical approval process was reached to make this a novel treatment. If it is not novel why present it as a case series?!
Response: Thank you for your excellent advice.
The resolution of the histology has been corrected, and enlarged photos have been added. Several successful cases of NPWT and skin grafting with immunosuppressive drugs for PG have been reported. However, the type and dosage of immunosuppressive drugs and the causes of postoperative recurrence have yet to be well described and are worth considering. Therefore, we present a case series of four cases. Of course, we recommend that other case series be accumulated in the future.
Reviewer 2 Report
The authors present an interesting case series of patients with the hard-to-treat diagnosis of pyoderma gangraenosum. Their findings support the necessity of a combination of surgical treatments and immunosuppressive drugs to control and promote healing of this complicated entity. The presentation is clear, however, sometimes to brief by lacking relevant clinical information for the reader. I have some questions and suggestions for changes:
Case 1: a) please indicate the type of diabetes mellitus b) What means "rapid" improvement. Please indicate time frames. c) What was the exact tapering strategy for PSL? d) On what day after start of PSL NPWT was initiated and what was the PSL dose at this moment? e) Please consider re-wording for "inner foot of the left lower leg", i.e. calf
Case 2: a) For how long was the patient treated with PSL 10mg/day? b) Please indicate the dose of adalimumab. c) "adalimumab and PSL were restarted at a dose of 5mg/day" is misleading. You mean adalimumab and PSL (5mg/day) were restarted... d) revise wording of the legend "was fine", i.e. successful.
Case 3: a) ulcer progression inhibited after how many days/weeks? Would be interesting to know..b) please explain what is meant by gradually.
Case 4: What was the dose of methotrexate and how was it administered (SC/orally)
Discussion: a) please add a reference to support disease burden of patients with PG. b) The reader might wonder what happened to the 4 patients (161-139-18 = 4) from reference 4. Please briefly discuss in relation to case 4.
Table: Can be improved. I.e. Case 1 with space, case 2 without space. Please indicate abbrevations used such as PSL or TAC. Introduce i.e. disease duration until initiation of immunosuppressive treatment. Time from start immunosuppressive treatment to surgery. Regarding transplantation site, please consider usage of medical terms i.e. ventral/dorsal and lateral/ medial...
Author Response
Responses to the comments of Reviewer #2
The authors present an interesting case series of patients with the hard-to-treat diagnosis of pyoderma gangraenosum. Their findings support the necessity of a combination of surgical treatments and immunosuppressive drugs to control and promote healing of this complicated entity. The presentation is clear, however, sometimes to brief by lacking relevant clinical information for the reader. I have some questions and suggestions for changes:
Case 1: a) please indicate the type of diabetes mellitus b) What means "rapid" improvement. Please indicate time frames. c) What was the exact tapering strategy for PSL? d) On what day after start of PSL NPWT was initiated and what was the PSL dose at this moment? e) Please consider re-wording for "inner foot of the left lower leg", i.e. calf
Response: Thank you for your several suggestions. We have supplemented the explanations and changed the manuscript according to your advice.
Case 2: a) For how long was the patient treated with PSL 10mg/day? b) Please indicate the dose of adalimumab. c) "adalimumab and PSL were restarted at a dose of 5mg/day" is misleading. You mean adalimumab and PSL (5mg/day) were restarted... d) revise wording of the legend "was fine", i.e. successful.
Response: Thank you for your advice. We have supplemented and changed the manuscript as indicated in the text.
Case 3: a) ulcer progression inhibited after how many days/weeks? Would be interesting to know..b) please explain what is meant by gradually.
Response: Thank you very much. We have supplemented and changed the manuscript.
Case 4: What was the dose of methotrexate and how was it administered (SC/orally)
Response: Thank you for your advice. She was taking methotrexate 4 mg/week orally. We have added this information to the text.
Discussion: a) please add a reference to support disease burden of patients with PG. b) The reader might wonder what happened to the 4 patients (161-139-18 = 4) from reference 4. Please briefly discuss in relation to case 4.
Response: Thank you for your great suggestion. We added a reference to support the disease burden of patients with PG. As for the remaining 4 cases, they were treated only with NPWT, which resulted in pain reduction and increased good granulation tissue, but no healing or recurrence was reported. So, we added different considerations related to our case 4. We appreciated your comments.
Table: Can be improved. I.e. Case 1 with space, case 2 without space. Please indicate abbrevations used such as PSL or TAC. Introduce i.e. disease duration until initiation of immunosuppressive treatment. Time from start immunosuppressive treatment to surgery. Regarding transplantation site, please consider usage of medical terms i.e. ventral/dorsal and lateral/ medial...
Response: Thank you for your important suggestion. We have revised the table and added a discussion regarding disease duration until initiation of immunosuppressive treatment and the time from the start of immunosuppressive treatment to surgery. Thank you for your excellent suggestion.
Round 2
Reviewer 2 Report
The authors sufficiently addressed my questions and comments. I feel the manuscript is now easier to follow and understand for the reader. In addition, the discussion was significantly improved.
Author Response
Responses to the comments of Reviewer #2
The authors sufficiently addressed my questions and comments. I feel the manuscript is now easier to follow and understand for the reader. In addition, the discussion was significantly improved.
Response: Thank you for your comments. We believe that the accumulation of information on the type and dosage of immunosuppressive drugs when PG patients undergo skin grafting or NPWT, including this report, will contribute to the discovery of an optimal treatment for PG.
